THE INCIDENCE OF RUGBY-RELATED CATASTROPHIC INJURIES (INCLUDING CARDIAC EVENTS) IN SOUTH AFRICA FROM For peer review only

Transcription

1 THE INCIDENCE OF RUGBY-RELATED CATASTROPHIC INJURIES (INCLUDING CARDIAC EVENTS) IN SOUTH AFRICA FROM 00-0 Journal: Manuscript ID: bmjopen-0-00 Article Type: Research Date Submitted by the Author: -Dec-0 Complete List of Authors: Brown, James; University of Cape Town, Human Biology Lambert, Mike; University of Cape Town, Human Biology Verhagen, Evert; VU University Medical Center, Public and Occupational Health Readhead, Clint; South African Rugby Union (SARU), Van Mechelen, Willem; VU University Medical Center, Public and Occupational Health Viljoen, Wayne; South African Rugby Union (SARU), <b>primary Subject Heading</b>: Sports and exercise medicine Secondary Subject Heading: Epidemiology, Public health, Emergency medicine Keywords: PREVENTIVE MEDICINE, EPIDEMIOLOGY, Orthopaedic sports trauma < ORTHOPAEDIC & TRAUMA SURGERY, Spine < ORTHOPAEDIC & TRAUMA SURGERY, SPORTS MEDICINE, AUDIT : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

2 Page of THE INCIDENCE OF RUGBY-RELATED CATASTROPHIC INJURIES (INCLUDING CARDIAC EVENTS) IN SOUTH AFRICA FROM 00-0 AUTHORS. Mr James C. Brown (corresponding author): UCT/MRC Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa (postal address) AND Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands. jamesbrown0@gmail.com Landline: +0 Fax: +0. Prof. Mike I. Lambert: UCT/MRC Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.. Dr Evert Verhagen Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.. Mr Clint Readhead: South African Rugby Union (SARU), SARU House, Uys Krige Road, Plattekloof, Cape Town, South Africa.. Prof. Willem Van Mechelen: Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; AND UCT/MRC Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

3 Page of Dr Wayne Viljoen: South African Rugby Union (SARU), SARU House, Uys Krige Road, Plattekloof, Cape Town, South Africa. Keywords: spinal cord injury; rugby; brain injuries; sports; sudden cardiac death Word count: Abstract = words. Word count excl abstract =. - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

4 Page of ABSTRACT Objectives: The primary aim was to establish an accurate and comprehensive injury incidence registry of all rugby-related catastrophic events in South Africa between An additional aim was to investigate correlates associated with these injuries. Design: Prospective Setting: Catastrophic injuries in the South African rugby-playing population. Participants: An estimated Junior and Senior rugby players (population at risk). Outcome measures: Annual average incidences of catastrophic injuries by type (cardiac events, traumatic brain and acute spinal cord injuries) and outcome (full recoveries - fatalities). Playing level (junior and senior level), position and event (phase of play) were also assessed. Results: The average annual incidence of Acute Spinal Cord Injuries (ASCI s) and Traumatic Brain Injuries (TBI s) combined was.00 per 0000 players (% CI s: 0..0) from The incidence of ASCI s with permanent outcomes was significantly higher at Senior (. per 0000 players, % CI s: 0..0) than Junior (0. per 0000 players, % CI s: 0 0.) level during this period. The hooker position was associated with % (n = of ) of all permanent ASCI outcomes, the majority of which (%) occurred during the scrum phase of play. - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

5 Page of Conclusions: The incidence of rugby-related catastrophic injuries in South Africa between 00-0 is comparable to that of other countries and to most other collision sports. The higher incidence rate of permanent ASCI s at the Senior level could be related to different law variations or characteristics compared to Junior level. The hooker and scrum were associated with high proportions of permanent ASCI s. The BokSmart injury prevention programme should focus efforts on these areas (Senior level, hooker and scrum) and use this study as a reference point for the evaluation of the effectiveness of the programme. Article Summary Article focus: Incidence of all catastrophic rugby-related injuries in South Africa between 00-0 and correlates that accounted for a high proportion of both all and permanent ASCI s. The three correlates that were strongly associated with catastrophic injuries (i.e. Senior age group, scrum phase of play and hooker position) should guide and focus BokSmart s prevention efforts. This study serves as a reference point for evaluating the effectiveness of the BokSmart programme going forward. Strengths and weaknesses: Strengths of the paper were the prospective design and comprehensive inclusion criteria for catastrophic injuries. Another strength was the novel statistical comparison and the finding of a higher incidence of catastrophic injury at the Senior level. A weakness of the study was the fact that the player numbers were assumed to have been constant for the entire period of investigation (00 0). - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

6 Page of INTRODUCTION While catastrophic events rarely occur in sport (), the long-term consequences and implicit severity of these events make them the most devastating of all injuries to the player, their family and friends (,). Up until the third decade of life, sport is associated with a large proportion of all catastrophic spinal injuries. Of all sports, collision games such as American Football, Ice Hockey and Rugby account for a large proportion of these sport- related catastrophic events (). Furthermore, Rugby Union (henceforth Rugby ) is currently the most popular collision sport worldwide () and has an enormous participant base with active international Unions ( Despite these participation levels, a recent review concluded that the level of risk of suffering a catastrophic injury while playing Rugby in the United Kingdom was acceptable (0. per 0000 participants). Furthermore, this annual incidence was not higher than that of other collision sports such as Rugby League (. per 0000 participants), Ice Hockey (. per 0000 participants) or American Football (.0 per participants) (). For South Africa in 00, the average annual incidence of rugbyrelated permanently disabling spinal cord injury was estimated to be lower (0. per participants) than other rugby-playing nations such as New Zealand, Ireland and Australia (). Despite these endorsements of the relatively low risk of catastrophic injury associated with rugby, an early South African study () concluded that % of all rugbyrelated spinal cord injuries reported, could potentially have been prevented (). It is these predictable and preventable catastrophic injuries that are the priority focus for injury prevention strategies (-). - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

7 Page of As a result, New Zealand s RugbySmart program ( was developed and proved successful in reducing catastrophic injuries ()(). Based on this success, the South African Rugby Union (SARU) developed their own program, BokSmart ( modelling it on a comparable intervention approach to New Zealand with additional components to suit the South African rugby landscape, making it an example of a National Sports Organization intervention (). Other catastrophic injury prevention strategies for rugby include Rugbyready (IRB) and Tackling Safety (England) (). To evaluate the effectiveness of the BokSmart programme, one first needs to establish the incidence and severity of catastrophic events (). Therefore, the primary aim of this paper is to describe the incidence of all types and outcomes of fatal and non-fatal rugby-related catastrophic injuries, in South Africa between 00 and 0. A secondary aim was to investigate correlates of these catastrophic injuries, which could guide and focus the preventative efforts of the BokSmart programme going forward. METHODS Data for this study were collected through the BokSmart program, which is a joint initiative between the South African Rugby Union (SARU)( and the Chris Burger/Petro Jackson Player s Fund (CBPJPF)( The CBPJPF is a non-profit public benefit organization (PBO), developed to aid players who have been permanently disabled while playing rugby in South Africa (). Permission to analyze the - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

8 Page of data was obtained, with SARU s and the CBPJPF s permission, by the UCT Human Research Ethics Committee. The following definitions were adopted for this manuscript (a more detailed description of the game of rugby union is available elsewhere ()): Catastrophic injury BokSmart and the CBPJPF use the following definition for recording catastrophic injuries: Any head, neck, spine or brain injury that is life-threatening, or has the potential to be permanently debilitating and results in the emergency admission of a rugby player to a hospital or medical care center. Cardiac events were also included and reported for this study. Catastrophic injuries were classified into three different groups:. Acute Spinal Cord Injury (ASCI),. Traumatic Brain Injury (TBI) and. Cardiac events. SCI s were further grouped into outcomes, listed in order of increasing severity: Near miss (full recovery expected, ambulant), Neurological deficit (some deficit remains, may walk with or without the requirement of assistive devices), Quadriplegic, and Fatal. TBI outcomes were divided into, with increasing severity: fully recovered, disability (remaining neurological deficit), and fatal. ASCI s and TBI s were further grouped into non-permanent (near misses/fully recovered) and permanent (residual disability, including fatalities). - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

9 Page of The outcomes presented are the hospital-confirmed diagnoses within one month after the initial injury date as this time frame was thought to be able to provide a more accurate diagnosis. Incidence The numerator was calculated as the number of catastrophic injuries and the denominator was the population at risk (total number of rugby players in South Africa). These player numbers were obtained from the International Rugby Board s (IRB s) website ( Incidences were presented as an annual average (over the four years) per 0000 players. Age group This term distinguished between Juniors and Seniors. Junior, which is synonymous with schoolboy in the South African context (under- to under-), and included pre-teen and teen males and females (as per IRB website). Senior, was comprised of anyone who was not in the definition for Junior for males and females (older than under-) and also included both amateurs and professionals. This term was used to describe the age group of match where the injury event occurred, regardless of whether the player was legitimately participating in that age group at the time. Event - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

10 Page of This term described the phase of play where the injury occurred and included scrum, ruck, tackle (this included both ball-carriers and tacklers) and collisions (an unintentional or intentional clash - which is distinct from a tackle ). Positional grouping Owing to small sample sizes, the fifteen general positions were grouped into nine positional groupings as per Durandt et al. (): prop (loose-head and tight head prop; = positions), hooker (= position), lock (left and right lock; = positions), loose-forward (open-side flank, blind-side flank and eighth man; = positions), scrumhalf ( = position), flyhalf ( = position), center (inside and outside center, = positions), wing (left and right wing; = positions), and fullback ( = position). Statistics Incidences with % confidence intervals were calculated using standard formulae (). Incidences were considered significantly different if the % confidence intervals did not overlap. Any negative lower % confidence limits were presented as 0. All presented proportions were calculated after excluding missing data (if present) for a particular section - the denominator is always indicated to remove ambiguity. - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

11 Page of RESULTS Since 00, there have been catastrophic injuries ( in Juniors and 0 in Seniors) recorded in total in South Africa (Table ), the majority of which (n = ) were Acute Spinal Cord Injuries (ASCI s). In Juniors, the highest number of injuries occurred in 00 (n = ), while for Seniors the highest number (n = ) occurred in both 00 and 0. Owing to small changes in numbers per year, incidences were calculated on the annual average of injuries over the four-year period (Table ). With an estimated players at both levels (Junior: n = ; Senior: n = ) in South Africa, the average annual incidence for all catastrophic injuries (TBI, Cardiac events and ASCI s) was.0 per 0000 players (% CI: 0. -.). The average annual incidence for all TBI s and ASCI s combined (excluding cardiac events) was.0 per 0000 Junior players (% CI s: 0.0.) and. per 0000 Senior players (% CI s:..0) (Combined =.00 per 0000 players, % CI s: 0..0) between 00 and 0. In combination, permanent TBI s and ASCI s occurred significantly more often at the Senior (. per 0000 players, % CI s..) than at the Junior level (0. per 0000 players, % CI s: 0 0.) between 00 and 0 (combined:. per 0000 players; % CI s: 0..0). The incidence of TBI s was 0. per 0000 Junior players (% CI s: 0 0.) and 0. per 0000 Senior players (% CI s: 0.0). The incidence of cardiac events was 0.0 per 0000 Junior players (% CI s: 0 0.) and 0. per 0000 Senior players (% CI s: 0 to.0). The point estimates calculated for TBI s and cardiac events should be - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

12 Page of interpreted with caution due to low number of these events (Table ). Half of the TBI s in Junior players (0%, n = of ) had full recoveries, while all outcomes in Senior players (0%, n = ) were fatal. Both cardiac events to date (n = ) had fatal outcomes. Owing to the low numbers of cardiac and TBI outcomes (n = ), subsequent analyses only focus on ASCI s. Table : Absolute numbers of serious/catastrophic injuries in Junior and Senior Rugby levels in South Africa by year, between 00 and 0 ( years, inclusive). Injuries are divided into type: Acute Spinal Cord Injury (ASCI), Traumatic Brain Injury (TBI) and Cardiac events and clinical outcome (indented below Type of injury). An annual average, which is the total number of events divided by the four years, is also provided. Table. Average annual incidences (based on IRB estimated numbers) of acute spinal cord injury (ASCI) from 00 0 in South Africa ( years, inclusive). Incidences include % confidence intervals (CI). Acute Spinal Cord injuries (ASCI s) are divided into outcomes: Not Provided, Non-permanent ( near misses ) and Permanent (neurological deficit, quadriplegic and fatal). Incidences are shown for Junior, Senior and Combined (Junior + Senior). - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

13 Page of Correlates of Acute Spinal Cord injuries (TBI s and cardiac events excluded): 00-0 All of the ASCI s occurred to males. Seven % of the ASCI s (n= of ) were fatal, % (n= of ) resulted in Quadriplegia, % (n= of ) resulted in neurological deficit and the remaining % (n= of ) were classified as Near Misses (outcome not provided in n = cases) (Table ). Henceforth for further comparison, outcomes of ASCI were also grouped as either Permanent (Neurological Deficit, Quadriplegia, Fatal) or Non-Permanent (Near Miss). The Senior level accounted for % (n = of ) of all ASCI s. Considering the population at risk numbers, the average annual incidence of all ASCI s (including not provided outcomes) displayed a strong tendency to be higher at the Senior (. per 0000 players, % CI s:..) compared to Junior level (0.0 per 0000 players, % CI s: 0.0.0) between 00 and 0 (Table ). In Senior players, % (n = of ) of all ASCI s had permanent outcomes (neurological deficit, quadriplegia or fatal) in comparison to % (n = of ) in Junior players. When considering the different numbers for the populations at risk, permanent ASCI s occurred significantly more often in Senior (. per 0000 players; 0..0) than Junior players (0. per 0000 players; 0 0.) (combined:.0 per 0000 players, % CI s: 0..) between 00 and 0 (Table ). Matches, as opposed to training, were associated with % (n = of ) of all ASCI s (information not available for n = cases). The training injuries occurred either in a scrum - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

14 Page of (n=), tackle (n=) or ruck (n=). Owing to the low numbers of training injuries and the fact that their mechanisms were similar to those that occurred in matches, these injuries were combined with match injuries for further analyses (Figures and ). The scrum was involved in % (n= of ) of all ASCI s. Sixty-three %(n= of ) of scrum-related ASCI s occurred to Senior players, which equates to an incidence of. injuries per Senior players (% CI s: 0 -.) between 00 and 0. Together, the scrum and tackle accounted for 0% (n= of ) of all ASCI s for both levels combined (Junior and Senior) (Figure A). Eighty-two %(n= of ; outcome not provided for n=) of scrum related injuries had permanent outcomes compared to 0% of tackle injuries (n= of ; outcome not provided for n=) (Table B). The scrum-related permanent ASCI outcomes equated to an average annual incidence of 0. permanent scrum ASCI s per 0000 players (% CI s: 0.) between 00 and 0. The Senior age group accounted for % (n= of ) of the permanent scrum injuries and % (n= of ) of the permanent tackle injuries. Of all the scrum injuries, scrum engagement and a collapsed scrum contributed to % and % of cases, respectively (n= and of, respectively; n= case was attributed to popping out, and information was not provided for n= case). The tackle events were evenly split between tackler and ball-carrier (n= for each). Figure. [A] The phase of play (Collision, Ruck, Scrum or Tackle) that accounted for all ASCI (n = ) and [B] permanent ASCI outcomes at Junior and Senior level. Segments add up to 0%. - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

15 Page of For further analyses, only n=0 cases were considered because four cases occurred in positional groupings that are not conventional -a-side rugby (n= seven-a-side, n= Mini-rugby) and the event responsible was unclear for one case. The hooker and loose-forward positional groupings were associated with % (n = of 0) and % (n= of 0) of all ASCI s (Figure A). Eighty % of all ASCI s to the hooker position were permanent injury outcomes (n= of ). Together, the hooker, prop, and lock positional grouping (tight five) accounted for all the scrum injuries. The tackle injuries were shared between all positional groupings except prop and scrumhalf. When examining permanent ASCI s in isolation (Figure B), only the forwards positional groupings were represented (prop, hooker, lock and loose-forward). Of these permanent outcomes, the hooker alone accounted for % (n= of ) of all injuries, % of which (n= of ) were as a result of the scrum. The loose-forward positional grouping accounted for % (n = of ) of all permanent outcomes, % (n = of ) of which came from the tackle. Figure. [A] The positional grouping, and the phase of play (tackle, scrum, ruck or collision) that accounted for all ASCI (n = 0) and [B] permanent ASCI (n=) outcomes. For all ASCI outcomes, four cases were excluded from the analysis as three were from Seven-a-side rugby and one was from Mini rugby. One case was excluded from both all ASCI and permanent outcomes as the event was unclear. All segments, in combination, add up to 0%. L-F = Loose-Forward; SH = Scrumhalf, FH = Flyhalf - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

16 Page of DISCUSSION In South Africa, the average annual incidence of all rugby-related catastrophic outcomes (excluding cardiac events) was.00 per 0000 players (% CI s: 0..0) between 00 and 0. This is comparable to the rate reported for Argentina (.0 per 0000 players) (0), between and and Ireland (0. per players) () between and 00. These are the only rugby-related catastrophic injury papers that included near miss outcomes and the incidences were only subsequently estimated by a recent review article (). While the current consensus statement for rugby injury data collection recognizes the importance of calculating incidences for comparability across playing nations (), it still does not include near miss outcomes in the definition of catastrophic injury. The small difference between non-permanent and permanent outcomes and therefore the epidemiological importance of including these outcomes has been stated by various authors in the past (,) and was clearly illustrated in a recent UK study of spinal injuries in junior players (). The variance in definition of a catastrophic injury influences the incidence, and therefore comparability with previous literature. The rugby union consensus statement () defines a catastrophic injury as a brain or spinal cord injury that results in permanent (> months) severe functional disability (loss of more than 0% of function). Yet, for effective prevention strategies, it has previously been contended that potentially permanently debilitating injuries, without permanent functional disability ( near misses ), should also be included in catastrophic injury studies (). This contention was further supported by a recent UK study () which concluded that near miss injuries had similar types and mechanisms of - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

17 Page of injury to their fellow players who had more severe outcomes, and are therefore included in this manuscript. Cardiac events are also not currently included in the current definition of catastrophic injury (), but are required ( by the International Rugby Board (IRB). For comparative purposes, the average annual incidence of permanent ASCI s and TBI s was. per players (% CI s: ) between 00 and 0. On a Health and Safety Executive scale () which categorises risk in ascending order, from negligible ( cases/0 000 population) to acceptable (0..0 cases per 0000 population); tolerable ( cases per population); and unacceptable (> 0 cases per 0000 population), this incidence would be classified as acceptable. This average incidence is also comparable to the rates reported in a review of rugby-related permanently disabling head and spinal injuries () in the UK (0..0 per 0000 players), but was on the lower end of rates reported for other countries (0..00 per 0000 players) in the same review. However, although this aforementioned review () intended to include both permanent TBI s and ASCI s, the majority of studies that were included only investigated the latter type of injury. Therefore, the average annual incidence of permanent ASCI s in the present study (.0 per players, % CI s: 0..) is the more comparable incidence to those presented in the review (). The incidence of permanent ASCI s in the present study is also similar to that reported for comparable outcomes in Australia between and 00 (. per 0000 players) () and New Zealand before (between. and., per 0000 players, per year) and after the introduction of RugbySmart (between 0. and., per : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

18 Page of players, per year) (). The incidence data of New Zealand is particularly believable and accurate due to their comprehensive no-fault insurance system (). The annual average incidence of the present study is also greater than the estimated incidence of permanent spinal cord injuries for South Africa between 00 and 00 (0. per 0000 players) (), although the earlier study had a different method of data collection to that of the present. For further comparison, the annual average incidence of non-fatal permanent ASCI s (excluding near misses and fatalities), for the present study was 0. per 0000 players (% CI s: 0..) which is significantly lower than the rate reported for comparable outcomes (ASIA scale A D, excluding fatalities) in Australia between and 00 (. per 0000 players, % CI s.0.) (), but comparable to France before (. per 0000 players, per year) and after the introduction of modified Laws and guidelines for the scrum (. per 0000 players, per year). Therefore, the main finding of the present study was the higher incidence of catastrophic injuries at the Senior, in comparison to the Junior level,. This associated factor, along with other relevant factors are described in the following section: Senior (as opposed to Junior) level The novel conclusion of the present study is that the annual average incidence of permanent ASCI s between 00 and 0 was significantly higher at the Senior (. per 0000 players, % CI s: 0..0) than Junior level (0. per 0000 players, % - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

19 Page of CI s: 0 0.). The Senior level also displayed a strong tendency to have a higher incidence for all ASCI outcomes (including near misses ) during the same period, although this difference was not statistically significant. Although incidences at Senior level have previously not been statistically compared with those at Junior level, preceding literature in Australia () and France () have indeed also reported higher incidences in Senior compared to Junior age groups. The best comparison to the present study was an American Football study () that investigated a comparable range of all ASCI outcomes per 0000 players: fatal to serious, with full recovery outcomes (equivalent to near miss in the present study). This American Football study had similar annual average incidences per 0000 high school and college players respectively to the present study:. (present study: 0.0 per 0000 players, % CI s: 0.0.0) and. (present study:. per 0000 players, % CI s:..). It was interesting to note that this study presents the first documented incidence of catastrophic injury in mini rugby (), although this injury had a near miss outcome. The reason for higher incidence rates at Senior level may, in part, be related to more stringent law variations, in particular with respect to the scrum, at Junior levels (). Law changes, particularly limiting how far a scrum can be pushed or wheeled, have decreased numbers of spinal cord injuries in New Zealand (0). However, the consistent finding that all (non-catastrophic as well as catastrophic) injury incidences rates are higher at Senior than Junior level (-) suggest that this finding is not unexpected. Studies investigating general injuries have suggested that increased speed () and increased competitiveness and aggression (,) may be responsible for the differences in incidences at these levels. - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

20 Page of Other factors such as weekend warriors (adults only playing sport on the weekend, without sufficient training, coaching and conditioning) and the low numbers of players at the senior level which could force players to play in unfamiliar positions, are potential contributing factors, although these require further investigation. Hooker positional grouping While the many positional groupings of rugby does not allow for statistical comparisons, the hooker positional grouping accounted for the highest proportion of all ASCI s (%) in the present study, which is alarming considering the small proportion (%, n = of ) that this position represents in a traditional -man starting line-up. Furthermore, this finding and comparison has been made in previous research in South Africa () and other countries (). Moreover, this position also accounted for the majority of all permanent ASCI s (%) in the present study, regardless of age group, and % of these (n = of ) were in the scrum. While the findings could not be investigated statistically, common-sense would argue that the large proportion of ASCI s attributed to this one specific playing position represents an alarming and concerning finding. Scrum (as opposed to any other phase of play) The scrum alone accounted for a rate of 0. ASCI s per 0000 players and for % of all ASCI s. The high proportion of scrum-related catastrophic injuries has previously been shown in South Africa () and other countries ()(). Additionally, there was a higher proportion of scrum-related catastrophic injuries in the present study (%) in - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

21 Page 0 of comparison to other studies which also included near misses, e.g. in Ireland (%, of ) (). However, studies that only investigated permanent outcomes found that the scrum accounted for % ( of ) of all cases in South Africa, % ( of ) of all cases in France, and % of all cases in Argentina (0), which were comparable in proportion to that of the present study (%). Independently, a higher proportion of scrum- compared to tackle-related ASCI s resulted in permanent outcomes (% vs. 0%). Considering that scrums occur relatively infrequently in comparison to tackles and rucks (), these findings are noticeably understated. While, the hooker, prop, and lock positional grouping (tight five) accounted for all the scrum-related permanent ASCI s, the tackle-related injuries were shared between all positional groupings except prop and scrumhalf, which represents the more generalised risk in the latter phase of play. While the incidence was not significantly different between age groups, % of all permanent scrum-related ASCI s occurred at the Senior rather than the Junior level. The engagement sequence accounted for the largest proportion of scrumrelated injuries (%) in the present study, which is consistent with previous findings () and has been attributed to the high forces experienced by the front row during this phase of the scrum (). The high forces (and thus acceleration) during engagement would exacerbate any predisposing risk factor. The premature degeneration of the cervical spine, particularly in front row players (), mismatches in size between front-row players (), and high impact forces () have been mentioned as potential factors for the relative overrepresentation of scrum-related injuries : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

22 Page of in previous literature, but other factors such as refereeing experience, coaching experience, scrum laws, technical preparation, appropriate player selection and specific conditioning of players should also be scrutinized more carefully. While the four phase crouch, touch, pause, engage (CTPE) refereeing sequence has been shown to have some positive effect on injury incidences (), the results of the present study warrants considering further Law changes with potentially greater effect, especially for the amateur game. The modification of scrum laws/regulations in amateur rugby in France: removal of the high impact on engagement, and linking the two packs together before the scrum commences, and a rugby passport license to certify capacity of frontrow players, significantly reduced scrum-related catastrophic cervical spine injuries, including those to the front-row and hooker positions (). Furthermore, the exemplary nationwide injury prevention program of New Zealand, RugbySmart, had a significant reduction in scrum-related spinal injuries () and it is hypothesized that the BokSmart program can produce a similar effect over time (). This paper serves as a reference point for the BokSmart program going forward. Although all ASCI s occurred to males in the present study, this may simply be an artefact of disproportionate participation levels: there are only females in comparison to males. The average annual incidence of cardiac death rates in the present study in Junior players (0.0 per 0000 players) is less than rates published previously for competitive athletes - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

23 Page of younger than years of age (). There were no prospective incidences available for adult/senior populations. Limitations Player numbers were assumed to remain constant over the four years of investigation. While they may have fluctuated between years, it is unlikely that numbers have declined appreciably, thereby ensuring that incidences were not under-estimated. The estimation of player numbers (population at risk) may also be open to error. However, due to the fact that these rare events are shown as an incidence per 0000 players, the inaccuracy would have to be enormous to affect the results presented in the current study. Furthermore, errors in numbers would probably be consistent at both levels (Junior and Senior) and should not drastically affect between-level comparisons. CONCLUSION In conclusion, the rates of all (including near-miss) and permanent (excluding near-miss) rugby-related ASCI s in South Africa from 00 to 0 are comparable to that of most other countries and to rates in other collision sports such as American Football. Despite this finding, three factors were strongly associated with catastrophic injury and warrant further attention for prevention strategies: Senior players, hooker playing position and the scrum phase of play. This four year registry will serve as reference point for the evaluation of the BokSmart injury prevention program going forward. - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

24 Page of ACKNOWLEDGMENTS The authors would like to thank the board of the Chris Burger/Petro Jackson Player s Fund (CBPJPF) and especially former Springbok captain, Morne Du Plessis, for his foresight in initiating the fund. The authors would also like to thank Ms Gail Ross, in her current position as Serious Injury Case Manager, for her dedication and effort in collecting the information that has been presented in this study. COMPETING INTERESTS None FUNDING This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. AUTHOR CONTRIBUTIONS CR and WV collected and entered the data for the project. All authors were involved in conceptualising of the manuscript. JB, ML, EV and WV were extensively involved in the data analysis and writing of this manuscript. All authors checked and edited the initial draft versions of the manuscript. - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

25 Page of DATA SHARING All data are securely kept on a SARU database that only WV and CR have access to. Due to the sensitive nature of the information, and appropriate medical ethics, access to any aspect of the available dataset will be reviewed upon request and on a discretionary basis. Sharing of only depersonalised and non-relatable data will be considered, once permission has been received from WV or CR (can be contacted through the corresponding author). REFERENCES. Fuller CW. Catastrophic injury in rugby union: is the level of risk acceptable? Sports Med. 00;():.. Quarrie KL, Cantu RC, CHALMERS DJ. Rugby union injuries to the cervical spine and spinal cord. Sports Med. 00;():.. Brooks JHM, Fuller CW. The influence of methodological issues on the results and conclusions from epidemiological studies of sports injuries: illustrative examples. Sports Med. 00;():.. Banerjee R, Palumbo MA, Fadale PD. Catastrophic cervical spine injuries in the collision sport athlete, part : epidemiology, functional anatomy, and diagnosis. Am J Sports Med. 00 Jun;():.. Hermanus FJ, Draper CE, Noakes TD. Spinal cord injuries in South African Rugby Union (0-00). S. Afr. Med. J. 0 Apr;0():0.. Kew T, Noakes TD, Kettles AN, Goedeke RE, Newton D, Scher AT. A retrospective study of - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

26 Page of spinal cord injuries in Cape Province rugby players, -. Aug ;0:.. Noakes T, Jakoet I, Baalbergen E. An apparent reduction in the incidence and severity of spinal cord injuries in schoolboy rugby players in the western Cape since 0. S. Afr. Med. J. ;():0.. Shelly M, Butler J, Timlin M, Walsh M, Poynton A, O'Byrne J. Spinal injuries in Irish rugby: a ten-year review. Journal of Bone and Joint Surgery-British Volume. JBJS (Br); 00;():.. Fuller C, Drawer S. The application of risk management in sport. Sports Med. 00;():.. Quarrie KL, Gianotti SM, Hopkins WG, Hume PA. Effect of nationwide injury prevention programme on serious spinal injuries in New Zealand rugby union: ecological study. BMJ. 00 Jun ;(0):0 0.. Noakes TD, Draper CE. Preventing spinal cord injuries in rugby union. BMJ. 00 Jun ;(0):.. Viljoen W, Patricios J. BokSmart - implementing a National Rugby Safety Programme. Br J Sports Med. 0 May.. Brown J. The introduction of an international model to reduce injuries in Rugby Union in South Africa. South African Journal of Sports Medicine. 0.. Finch CF, Donaldson A. A sports setting matrix for understanding the implementation context for community sport. Br J Sports Med.. 0 Oct ;():.. van Mechelen W, Hlobil H, Kemper H. Incidence, severity, aetiology and prevention of sports - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

27 Page of injuries. A review of concepts. Sports Med. Aug ;():.. Tebbutt P. Samaritan of South African Rugby. Sun Press; 0.: -.. Duthie G, Pyne D, Hooper S. Applied physiology and game analysis of rugby union. Sports Med. 00;():.. Durandt J, Toit Du S, Borresen J, Hew-Butler T. Fitness and body composition profiling of elite junior South African rugby players: original research article. South African Journal of Sports Medicine Knowles SB, Marshall SW, Guskiewicz KM. Issues in estimating risks and rates in sports injury research. J Athl Train. National Athletic Trainers Association; 00;():0. 0. Secin FP, Poggi EJ, Luzuriaga F, Laffaye HA. Disabling injuries of the cervical spine in Argentine rugby over the last 0 years. Br J Sports Med. Feb ;():.. Fuller CW, Molloy MG, Bagate C, Bahr R, Brooks JHM, Donson H, et al. Consensus statement on injury definitions and data collection procedures for studies of injuries in rugby union. Br J Sports Med. 00 Jan ;():.. Rotem T, Lawson J, Wilson S. Severe cervical spinal cord injuries related to rugby union and league football in New South Wales, -. Med. J. Aust. Apr ;():.. Noakes T, Jakoet I. Spinal cord injuries in rugby union players. BMJ. May ;():.. MacLean JG, Hutchison JD. Serious neck injuries in U rugby union players: an audit of admissions to spinal injury units in Great Britain and Ireland. Br J Sports Med. 0 Dec. - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

28 Page of Carmody DJ, Taylor TKF, Parker DA, Coolican MRJ, Cumming RG. Spinal cord injuries in Australian footballers -00. Med. J. Aust. 00 Jun ;():.. Gianotti SM, Quarrie KL, Hume PA. Evaluation of RugbySmart: A rugby union community injury prevention programme. J Sci Med Sport. 00 May;():.. Berry JG, Harrison JE, Yeo JD, Cripps RA, Stephenson SCR. Cervical spinal cord injury in rugby union and rugby league: are incidence rates declining in NSW? Aust N Z J Public Health. 00 Jun;0():.. Bohu Y, Julia M, Bagate C, Peyrin JC, Colonna JP, Thoreux P, et al. Declining Incidence of Catastrophic Cervical Spine Injuries in French Rugby: -00. Am J Sports Med. 00 Feb ;():.. Boden BP, Tacchetti RL, Cantu RC, Knowles SB, Mueller FO. Catastrophic cervical spine injuries in high school and college football players. Am J Sports Med.. 00 Aug;():. 0. Burry HC, Calcinai CJ. The need to make rugby safer. BMJ (Clin Res Ed). Jan ;(): 0.. Bird YN, Waller AE, Marshall SW, Alsop JC, Chalmers DJ, Gerrard DF. The New Zealand Rugby Injury and Performance Project: V. Epidemiology of a season of rugby injury. Br J Sports Med. Dec;():.. Lee AJ, Garraway WM. Epidemiological comparison of injuries in school and senior club rugby. Br J Sports Med. Sep ;0():.. Roux C, Goedeke R, Visser G, Van Zyl W, Noakes T. The epidemiology of schoolboy rugby - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

29 Page of injuries. S. Afr. Med. J.. Mar ;():0.. Board IR. IRB JUNIOR WORLD CHAMPIONSHIP 0: STATISTICAL REVIEW AND MATCH ANALYSIS. icalreport.pdf. 0. pages. Accessed: April 0.. Milburn PD. Biomechanics of rugby union scrummaging. Technical and safety issues. Sports Med. Sep;():.. Scher AT. Premature onset of degenerative disease of the cervical spine in rugby players. S. Afr. Med. J. 0 Jun ;():.. Gianotti S, Hume PA, Hopkins WG, Harawira J, Truman R. Interim evaluation of the effect of a new scrum law on neck and back injuries in rugby union. Br J Sports Med. 00 Apr ;(): 0.. Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, et al. Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 00 Update: A Scientific Statement From the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: Endorsed by the American College of Cardiology Foundation. Circulation. 00 Mar ;():. - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

30 Page of Table : Absolute numbers of serious/catastrophic injuries in Junior and Senior Rugby levels in South Africa by year, between 00 and 0 ( years, inclusive). Injuries are divided into type: Acute Spinal Cord Injury (ASCI), Traumatic Brain Injury (TBI) and Cardiac events and clinical outcome (indented below Type of injury). An annual average, which is the total number of events divided by the four years, is also provided. Type of injury TOTAL Annual Average Acute Spinal Cord Injury (ASCI) [n = ] Junior Senior Junior Senior Junior Senior Junior Senior Junior Senior Junior Senior "Near miss" (full recovery/ambulant) Neurological deficit Quadriplegics Fatal Not Provided Traumatic Brain Injury (TBI) [n = ] Fully recovered Disability Fatal Cardiac events [n = ] Fatal TOTAL Average is calculated for the four years that data has been collected. 0 on September 0 by guest. Protected by copyright. - : first published as./bmjopen-0-00 on February 0. Downloaded from

31 Page 0 of Table. Average annual incidences (based on IRB estimated numbers) of acute spinal cord injury (ASCI) from 00 0 in 0 South Africa ( years, inclusive). Incidences include % confidence intervals (CI). Acute Spinal Cord injuries (ASCI s) are 0 divided into outcomes: Not Provided, Non-permanent ( near misses ) and Permanent (neurological deficit, quadriplegic and fatal). Incidences are shown for Junior, Senior and Combined (Junior + Senior). Junior Senior Combined ASCI outcome Incidence (% CI) Incidence (% CI) Incidence (% CI) Permanent (ND + Quad. + Fatal) 0. (0 0.). (0..0).0 (0..) Neurological deficit (ND) 0. (0 0.).0 (0.0) 0.0 (0.0) Quadriplegics (Quad.) 0.0 (0 0.). (0.) 0. (0 0.) Fatal 0 ( ) 0. (0.0) 0. (0 0.) Non-permanent ("Near miss") 0. (0.) 0. (0.0) 0. (0.) Not Provided* 0.0 (0 0.) 0. (0.0) 0. (0 0.) Total ASCI's 0.0 (0.0.0). (..). (0..) *Specific diagnosis not available/supplied, but confirmed as ASCI ASCI Acute Spinal Cord Injury Bold text indicates value is significantly different from Junior level : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

32 Page of : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

33 Page of : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

34 Page of A] The phase of play (Collision, Ruck, Scrum or Tackle) that accounted for all ASCI (n = ) and [B] permanent ASCI outcomes at Junior and Senior level. Segments add up to 0%. xmm (00 x 00 DPI) - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.

35 Page of [A] The positional grouping, and the phase of play (tackle, scrum, ruck or collision) that accounted for all ASCI (n = 0) and [B] permanent ASCI (n=) outcomes. For all ASCI outcomes, four cases were excluded from the analysis as three were from Seven-a-side rugby and one was from Mini rugby. One case was excluded from both all ASCI and permanent outcomes as the event was unclear. All segments, in combination, add up to 0%. L-F = Loose-Forward; SH = Scrumhalf, FH = Flyhalf xmm (00 x 00 DPI) - : first published as./bmjopen-0-00 on February 0. Downloaded from on September 0 by guest. Protected by copyright.